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The laryngeal mask airway (LMA) is commonly used for airway management. Cuff hyperinflation has been associated with complications, poor ventilation and increased risk of gastric insufflation. This study was designed to determine the best cuff inflation method of AuraOnce™ LMA during bronchoscopy and EBUS (Endobronquial Ultrasound Bronchoscopy) procedure. We designed a Randomized controlled, doble-blind, clinical trial to compare the efficacy and safety of three cuff inflation methods of AuraOnce™ LMA. 210 consenting patients scheduled for EBUS procedure under general anesthesia, using AuraOnce™ LMA were randomized into three groups depending on cuff insufflation: residual volume (RV), half of the maximum volume (MV), unchanged volume (NV). Parameters regarding intracuff pressure (IP), airway leak pressure (OLP), leakage volume (LV) were assessed, as well as postoperative complications (PC). 201 (95.7%) patients completed the study. Mean IP differed between groups (MV: 59.4 ± 32.4 cm H2O; RV: 75.1 ± 21.1 cm H2O; NV: 83.1 ± 25.5 cmH20; P < 0.01). The incidence of IP > 60 cmH2O was lower in the MV group compared to the other two (MV: 20/65(30.8%); RV:47/69 (68.1%); NV 48/67 (71.6%); p < 0.01). The insertion success rate was 89,6% (180/201) at first attempt, with no difference between groups (p = 0.38). No difference between groups was found either for OLP (p = 0.53), LV (p = 0.26) and PC (p = 0.16). When a cuff manometer is not available, a partial inflation of AuraOnce™ LMA cuff using MV method allows to control intracuff pressure, with no significant changes of OLP and LV compared to RV and NV insufflation method.Registration clinical trial: NCT04769791.
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Insuflación , Máscaras Laríngeas , Humanos , Máscaras Laríngeas/efectos adversos , Insuflación/efectos adversos , Anestesia General/métodos , Complicaciones Posoperatorias/etiología , Manejo de la Vía Aérea/efectos adversosRESUMEN
Purpose of Review: Our goal in this review is to describe the current context and peculiarities of obstetric anaesthesia in low- and middle-income countries (LMIC) and the ongoing actions and perspectives in terms of teaching and learning, focusing on improving maternal outcomes. Recent Findings: Correct identification of barriers and lack of infrastructures and anaesthesia providers are still major problems despite efforts of different stakeholders. International consensus and commitment for 2030 goals are trying to be achieved. Summary: Structured training courses look a good option as short- and long-term evaluations show a positive impact. Future efforts will have to be also focused on indicators that may help to decrease the high mortality and morbidity ratios in LMIC.
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(1) Background: Surgical outcomes in free flap reconstruction of head and neck defects in cancer patients have improved steadily in recent years; however, correct anaesthesia management is also important. The aim of this study has been to show whether goal directed therapy can improve flap viability and morbidity and mortality in surgical patients. (2) Methods: we performed an observational case control study to analyse the impact of introducing a semi invasive device (Flo Trac®) during anaesthesia management to optimize fluid management. Patients were divided into two groups: one received goal directed therapy (GDT group) and the other conventional fluid management (CFM group). Our objective was to compare surgical outcomes, complications, fluid management, and length of stay between groups. (3) Results: We recruited 140 patients. There were no differences between groups in terms of demographic data. Statistically significant differences were observed in colloid infusion (GDT 53.1% vs. CFM 74.1%, p = 0.023) and also in intraoperative and postoperative infusion of crystalloids (CFM 5.72 (4.2, 6.98) vs. GDT 3.04 (2.29, 4.11), p < 0.001), which reached statistical significance. Vasopressor infusion in the operating room (CFM 25.5% vs. GDT 74.5%, p < 0.001) and during the first postoperative 24h (CFM 40.6% vs. GDT 75%, p > 0.001) also differed. Differences were also found in length of stay in the intensive care unit (hours: CFM 58.5 (40, 110) vs. GDT 40.5 (36, 64.5), p = 0.005) and in the hospital (days: CFM 15.5 (12, 26) vs. GDT 12 (10, 19), p = 0.009). We found differences in free flap necrosis rate (CMF 37.1% vs. GDT 13.6%, p = 0.003). One-year survival did not differ between groups (CFM 95.6% vs. GDT 86.8%, p = 0.08). (4) Conclusions: Goal directed therapy in oncological head and neck surgery improves outcomes in free flap reconstruction and also reduces length of stay in the hospital and intensive care unit, with their corresponding costs. It also appears to reduce morbidity, although these differences were not significant. Our results have shown that optimizing intraoperative fluid therapy improves postoperative morbidity and mortality.
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PURPOSE OF REVIEW: This review is based on the latest evidence to provide a good standard of care for COVID-19 parturients and protection to healthcare givers. RECENT FINDINGS: COVID-19 by itself is not an indication for cesarean section. Different publications demonstrated the efficacy of neuraxial analgesia/anesthesia for delivery. Although SARS-CoV-2 was associated with a certain neurotropism, neuraxial block was not associated with neurological damage in COVID-19 parturients, and seems as safe and effective as in normal situations. It permits to avoid a general anesthesia in case of intrapartum cesarean section. Epidural failure is a concern: it may lead to a general anesthesia in case of emergency cesarean section. Local protocols and well-trained anesthesiologists will be helpful. COVID-19 patients require special circuits and every step (transfer to and from theatre, recovery, analgesia, and so on) should be planned in advance. For cesarean section under general anesthesia, personal protection equipment must be enhanced. Postoperative analgesia with neuraxial opioids, NSAIDs, or regional blocks are recommended. COVID-19 and pregnancy increase the risk of thrombosis, so thromboprophylaxis has to be considered and protocolized. SUMMARY: Anesthetic care for delivery in COVID-19 parturients should include neuraxial blocks. Special attention should be paid on the risk of thrombosis.
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Analgesia Obstétrica , COVID-19 , Cesárea , Obstetricia , Analgesia Obstétrica/efectos adversos , Anticoagulantes , Femenino , Humanos , Embarazo , Tromboembolia VenosaRESUMEN
Free flap surgery is the gold standard surgical treatment for head and neck defects in cancer patients. Outcomes have improved considerably, probably due to recent advances in surgical techniques. In this article, we review improvements in the parameters traditionally used to optimize hematocrit levels and body temperature and to prevent vasoconstriction, and describe the use of cardiac output-guided fluid management, a technique that has proved useful in other procedures. Finally, we review other parameters used in free flap surgery, such as clotting/platelet management and nutritional optimization.
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Colgajos Tisulares Libres , Neoplasias de Cabeza y Cuello , Procedimientos de Cirugía Plástica , Colgajos Tisulares Libres/cirugía , Cabeza/cirugía , Neoplasias de Cabeza y Cuello/cirugía , Humanos , Cuello/cirugía , Estudios RetrospectivosRESUMEN
OBJECTIVES: Although there are different ways of performing medial branch neurotomy on facetogenic low back pain, few studies have compared clinical outcomes of a parallel technique over the medial branch vs. a perpendicular technique. We investigated differences in pain outcome with both techniques. DESIGN: This was a prospective, pilot, randomized, pragmatic trial (double blinded in the diagnostic phase). SETTING: A comparative pilot trial was conducted at an academic pain center. METHODS: Patients who did not respond to conservative medications and had severe lumbar pain for more than 3 months (VAS score ≥ 65) were included. A double diagnostic block with local anesthetic and placebo was performed, double blinded. Patients who had 80% relief from the local anesthetic and no substantial relief from placebo were randomized to undergo medial branch neurotomy under fluoroscopy, placing an electrode parallel or perpendicular to the medial branch. The primary outcome was differences in the VAS score at 1, 3, and 6 months. The secondary outcomes were Oswestry Disability Index score, Roland Morris Questionnaire score, and other functional Likert scale scores. RESULTS: Forty-three consecutive patients were randomized to parallel (n = 20) or perpendicular (n = 23) neurotomy. There were no significant differences in VAS, Oswestry Disability Index, or Roland Morris Questionnaire scores at 1, 3, or 6 months between groups. Statistically significant differences were found in the categorical analysis at 6 months in the evolution of pain, Oswestry Disability Index score, Roland Morris Questionnaire score, and some Likert scale scores in favor of the parallel group. CONCLUSIONS: There were differences at 6 months in the categorical analysis of the evolution of pain, Oswestry Disability Index score, Roland Morris Questionnaire score, and some functional Likert scale scores, all in favor of the parallel group.
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Desnervación/instrumentación , Desnervación/métodos , Dolor de la Región Lumbar/terapia , Adulto , Anciano , Electrodos , Femenino , Humanos , Región Lumbosacra , Masculino , Persona de Mediana Edad , Proyectos Piloto , Estudios Prospectivos , Resultado del Tratamiento , Articulación CigapofisariaRESUMEN
PURPOSE OF REVIEW: Even if its use is scarce in most countries, many articles concerning combined spinal epidural (CSE) were published. In this review, we present the latest advances concerning CSE in obstetrics. RECENT FINDINGS: During labour, CSE improves epidural analgesia quality. Epidural with intradural opioids can produce maternal hypotension and foetal heart rate abnormalities (FHR-Ab), without increasing the caesarean section rate. For caesarean section, CSE decreases the neuraxial block failure rate, with no significant increase of complications. Epidural volume extension (EVE) after CSE for caesarean section could be an interesting option even though more evidence is needed. SUMMARY: For labour analgesia, CSE has the fastest onset time of analgesia. Its side effects have no consequences on maternal, labour or foetal outcomes. It provides better analgesia than epidural analgesia and can be used for external cephalic version and high-risk patients. For caesarean section, CSE has become the reference neuraxial technique for low-dose spinal anaesthesia, with higher success rate compared with regular spinal anaesthesia. Recent systematic revisions did not confirm this superiority. CSE offers the advantage of EVE, intraoperative top-ups, postoperative administration of neuraxial opioids and local anaesthetics. The risk of complications is balanced by the benefits of the technique.
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Analgesia Epidural , Analgesia Obstétrica , Anestesia Raquidea , Anestésicos Combinados/administración & dosificación , Analgesia Epidural/efectos adversos , Analgesia Obstétrica/efectos adversos , Anestesia Obstétrica , Anestesia Raquidea/efectos adversos , Cesárea , Espacio Epidural , Femenino , Humanos , EmbarazoRESUMEN
BACKGROUND: Breakthrough pain (BTP) is a common problem during labor analgesia. Programmed intermittent epidural bolus (PIEB) has demonstrated superior to background epidural infusion (BEI) concerning BTP, but the effect of combining both modes remains unknown. We hypothesized that this combination could reduce BTP incidence. METHODS: Nulliparous parturients with early cervical dilation were randomized to receive 5 mL/h BEI of levobupivacaine 0.125% plus fentanyl 1.45 µg/mL (standard group) or 5 mL/h BEI + 10 mL/h PIEB (PIEB group). In case of BTP, patient-controlled epidural analgesia (PCEA) boluses of 10 mL (20-min lockout interval) were administered. If PCEA was insufficient, a 10-mL clinician bolus was delivered. The primary endpoint was the percentage of parturients who required supplementary epidural boluses. RESULTS: One hundred and twenty women were recruited. Eighty-nine percent of parturients required supplementary boluses in standard group versus 30% in PIEB group (RR=3.07; 95% CI: 1.99-4.76; P<0.001). Adding PIEB prevented BTP in 70% of cases. Duration of effective analgesia was longer in PIEB than in standard group (P=0.003). Supplementary boluses were decreased (P<0.001), while local anesthetic consumption increased (P<0.001) by PIEB addition. Sensory-motor block, mode of delivery, maternal satisfaction and neonatal outcomes were equally distributed in both groups. CONCLUSIONS: Adding PIEB to BEI+PCEA improved labor analgesia by significantly reducing the needs of rescue analgesia and prolonging the duration of effective analgesia. This combination provoked a higher consumption of local anesthetic with no detected clinical consequences.
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Analgesia Epidural/métodos , Analgesia Obstétrica/métodos , Dolor Irruptivo/prevención & control , Dolor de Parto , Adolescente , Adulto , Anestésicos Intravenosos/administración & dosificación , Anestésicos Locales/administración & dosificación , Determinación de Punto Final , Femenino , Fentanilo/administración & dosificación , Humanos , Recién Nacido , Levobupivacaína/administración & dosificación , Bloqueo Nervioso , Dimensión del Dolor , Paridad , Embarazo , Resultado del Embarazo , Adulto JovenRESUMEN
PURPOSE OF REVIEW: The objective of this review is to analyze and summarize the current anesthetic methods used to alleviate pain and discomfort during transvaginal oocyte retrieval procedures (TORP), to try to reach practical recommendations, based on the evidence, which will translate into daily practice, the knowledge on the anesthetic management of patients scheduled for TORP. RECENT FINDINGS: There is no strong evidence to recommend the avoidance of any technique or drug for TORP, including nitrous oxide or halogenated agents. Women should be offered any available technique. The evidence available up to date is not convincing enough to recommend avoiding any anesthetic technique in terms of pregnancy and birth rates. SUMMARY: TORP is painful for women and different techniques may be used for pain relief in day case surgery. The other important outcome to consider is the pregnancy rate, and any anesthetic technique or drug which would improve this pregnancy rate should be recommended. Conscious sedation and general anesthesia proved to be well tolerated for woman and the oocytes, despite the use of propofol, opioids, benzodiacepines, nitrous oxide, or other drugs. Spinal anesthesia and paracervical block are also acceptable options, and can be combined with conscious sedation. Nevertheless, more studies are needed to find out the ideal drug or technique combination for the woman and the oocyte.
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Analgesia/normas , Anestesia/normas , Sedación Consciente/normas , Recuperación del Oocito/efectos adversos , Dolor/prevención & control , Analgesia/efectos adversos , Analgesia/métodos , Analgésicos/administración & dosificación , Analgésicos/efectos adversos , Anestesia/efectos adversos , Anestesia/métodos , Anestésicos por Inhalación/administración & dosificación , Anestésicos por Inhalación/efectos adversos , Anestésicos Locales/administración & dosificación , Anestésicos Locales/efectos adversos , Sedación Consciente/efectos adversos , Sedación Consciente/métodos , Femenino , Humanos , Recuperación del Oocito/métodos , Dolor/etiología , Guías de Práctica Clínica como Asunto , Resultado del TratamientoRESUMEN
BACKGROUND: The Zero-Heat-Flux technology of the SpotOn® sensor to measure core temperature has been validated in vascular and cardiac surgery. Our aim was to assess its validity in gynecological surgery in terms of time of measurement, thermic status (hypo-, normo-, or hyperthermia) and the use of different warming devices. METHODS: Prospective study in patients scheduled for major gynecological surgery using three warming systems (Snuggle Warm®, Lithotomy Underbody Blanket® and Warmtac Pad®). Intraoperative temperature was simultaneously monitored using the SpotOn® sensor and a Dräger® esophageal probe; measurements were taken after induction (T0), between 0 and 60 min (T1), between 60 and 120 minutes (T2) and after 120 minutes (T3). We calculated the level of correlation between pairs of measurements both overall and in subgroups with an acceptable difference of less than 0.5 °C. We built Bland-Altman plots, and calculated the Pearson correlation (PC) and intraclass correlation coefficient (ICC) to test our data. RESULTS: We recruited 70 patients and included 66 for analysis, giving a total of 401 paired measurements. Overall, the PC and ICC for paired temperature readings were 0.82 and 0.90, respectively. The lowest levels of correlation were observed after intubation, when a convective blanket was placed under the patient, and in hypothermic patients. The highest correlations were observed at T2, and in normothermic patients. CONCLUSIONS: We found a high overall correlation between the SpotOn® and the esophageal probe, with negligible differences and almost perfect agreement. The warming system used, time of measurement, and thermic status appear to influence the level of correlation, but these differences were not clinically significant.
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Temperatura Corporal , Esófago/fisiología , Procedimientos Quirúrgicos Ginecológicos , Monitoreo Intraoperatorio/instrumentación , Termómetros , Adulto , Anciano , Diseño de Equipo , Femenino , Humanos , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
OBJECTIVE: Postdural puncture headache (PDPH) is the most common serious complication in obstetric anesthesia. We show the incidence of accidental dural puncture (ADP), PDPH, epidural blood patch (EBP) and associated morbidity following a protocol established in an obstetric anesthesia department. METHODS: An observational, prospective, analytical study performed in 66,540 epidural labor analgesia procedures. The objective is to describe the incidence of ADP, PDPH and EBP in a large obstetric anesthesia population, as well as morbidity associated with ADP and EBP. RESULTS: Incidence of ADP and PDPH was 0.76% and 59%, respectively, and the global incidence of EBP was 0.2%. Experience of the anesthetist performing the epidural (1st or 2nd year resident) and night shift were correlated with ADP. Low back pain was more frequent in patients undergoing EBP. CONCLUSIONS: We found an incidence of ADP and PDPH of 0.76% and 59%, respectively. Experience of the anesthetist performing the epidural (1st or 2nd year resident) and night shift were correlated with ADP. EBP is a safe, easy and acceptable treatment for PDPH, despite a higher risk of low back pain.
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Anestesia Obstétrica/efectos adversos , Parche de Sangre Epidural , Cefalea Pospunción de la Duramadre/epidemiología , Adulto , Femenino , Humanos , Incidencia , Cefalea Pospunción de la Duramadre/terapia , Embarazo , Estudios Prospectivos , Punción Espinal/efectos adversosRESUMEN
BACKGROUND: Dosing in obese critically ill patients is challenging due to pathophysiological changes derived from obesity and/or critical illness, and it remains fully unexplored. This study estimated the micafungin probability of reaching adequate 24-h area under the curve (AUC0-24h)/minimum inhibitory concentration (MIC) values against Candida spp. for an obese/nonobese, critically ill/noncritically ill, large population. METHODS: Blood samples for pharmacokinetic analyses were collected from 10 critically ill nonobese patients, 10 noncritically ill obese patients, and 11 critically ill morbidly obese patients under empirical/directed micafungin treatment. Patients received once daily 100-150 mg micafungin at the discretion of the treating physician following the prescribing information and hospital guidelines. Total micafungin concentrations were determined by high-performance liquid chromatography (HPLC). Monte-Carlo simulations were performed and the probability of target attainment (PTA) was calculated using the AUC0-24/MIC cut-offs 285 (C. parapsilosis), 3000 (all Candida spp.), and 5000 (nonparapsilosis Candida spp.). Intravenous once-daily 100-mg, 150-mg, and 200-mg doses were simulated at different body weights (45, 80, 115, 150, and 185 kg) and age (30, 50, 70 and 90 years old). PTAs ≥ 90% were considered optimal. Fractional target attainment (FTA) was calculated using published MIC distributions. A dosing regimen was considered successful if the FTA was ≥ 90%. RESULTS: Overall, 100 mg of micafungin was once-daily administered for nonobese and obese patients with body mass index (BMI) ≤ 45 kg/m2 and 150 mg for morbidly obese patients with BMI > 45 kg/m2 (except two noncritically ill obese patients with BMI ~ 35 kg/m2 receiving 150 mg, and one critically ill patient with BMI > 45 kg/m2 receiving 100 mg). Micafungin concentrations in plasma were best described using a two-compartment model. Weight and age (but not severity score) were significant covariates and improved the model. FTAs > 90% were obtained against C. albicans with the 200 mg/24 h dose for all body weights (up to 185 kg), and with the 150 mg/24 h for body weights < 115 kg, and against C. glabrata with the 200 mg/24 h dose for body weights < 115 kg. CONCLUSION: The lack of adequacy for the 100 mg/24 h dose suggested the need to increase the dose to 150 mg/24 h for C. albicans infections. Further pharmacokinetic/pharmacodynamic studies should address optimization of micafungin dosing for nonalbicans Candida infections.
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Candidiasis/tratamiento farmacológico , Relación Dosis-Respuesta a Droga , Equinocandinas/farmacología , Equinocandinas/farmacocinética , Lipopéptidos/farmacología , Lipopéptidos/farmacocinética , Obesidad Mórbida/fisiopatología , Obesidad/fisiopatología , Adulto , Anciano , Anciano de 80 o más Años , Antifúngicos/farmacocinética , Antifúngicos/farmacología , Antifúngicos/uso terapéutico , Área Bajo la Curva , Índice de Masa Corporal , Enfermedad Crítica/terapia , Equinocandinas/uso terapéutico , Femenino , Humanos , Lipopéptidos/uso terapéutico , Masculino , Micafungina , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Método de Montecarlo , Curva ROC , EspañaRESUMEN
BACKGROUND: The best technique to identify the epidural space for labor analgesia is still unclear despite the publication of various randomized controlled studies and meta-analyses. Our aim was to assess the superiority of the saline loss of resistance (SLOR) technique over the air loss of resistance (ALOR) technique with respect to the quality of the block. METHODS: Consenting parturients admitted to our obstetric suite for spontaneous or induced labor were randomized to receive epidural analgesia using either the ALOR or SLOR technique. Our primary outcome was to compare the impact of the SLOR and ALOR technique on pain score improvement measured 30 minutes after administration of epidural block. Our secondary outcomes included the density of motor blockade and analgesic efficacy measured at 30 minutes. Primary and secondary outcomes were compared using the Student t test and Mann-Whitney U test. Statistical significance was set at P < .017 for primary and secondary outcomes, considering Bonferroni correction for multiple comparisons. Other comparisons were considered exploratory. RESULTS: Four hundred parturients were included; 24 were excluded from the final analysis. After 30 minutes, pain score reduction (ALOR, 4.7 ± 2.9/10; SLOR, 4.9 ± 3.0/10; P = .49), motor block (ALOR, 1.4 ± 0.8; SLOR, 1.3 ± 0.8; P = .27), and efficacy of the block (ALOR, 1.0 ± 0.7; SLOR, 1.0 ± 0.6; P = .87) did not differ significantly between groups. CONCLUSIONS: Pain score reduction after 30 minutes and onset of the block were not affected by the technique used to locate the epidural space.
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Aire , Analgesia Epidural/métodos , Espacio Epidural/efectos de los fármacos , Trabajo de Parto/efectos de los fármacos , Solución Salina/administración & dosificación , Adulto , Analgesia Epidural/tendencias , Método Doble Ciego , Espacio Epidural/fisiología , Femenino , Humanos , Trabajo de Parto/fisiología , Dimensión del Dolor/efectos de los fármacos , Dimensión del Dolor/métodos , Embarazo , Estudios ProspectivosRESUMEN
Given the growing incidence of invasive candidiasis in critically ill and haemato-oncological patients and its poor outcomes, an early diagnosis and treatment are need for get a better prognosis. This document reviews the current approaches that help in diagnosis of invasive candidiasis based on culture-independent microbiological tests. The combination of clinical prediction scores with fungal serological markers could facilitate the approach in antifungal therapy, optimizing it. This article also reviews the epidemiology and primary risk factors for invasive candidiasis in these patients, updating the therapeutic approach algorithms in both clinical contexts based on the main evidence and international guidelines (AU)
Dada la creciente incidencia de candidiasis invasiva en pacientes críticos y hematooncológicos y sus malos resultados, es necesario un diagnóstico y tratamiento precoz para obtener un mejor pronóstico. Este documento revisa los enfoques actuales que ayudan en el diagnóstico de candidiasis invasiva basado en pruebas microbiológicas independientes del cultivo. La combinación de puntuaciones de predicción clínica con marcadores serológicos fúngicos podría facilitar el enfoque en la terapia antifúngica, optimizándola. Este artículo también revisa la epidemiología y los principales factores de riesgo de candidiasis invasiva en estos pacientes, actualizando los algoritmos de abordaje terapéutico en ambos contextos clínicos basados en la evidencia publicada y en las guías internacionales (AU)
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Humanos , Candidiasis Invasiva/tratamiento farmacológico , Candida/patogenicidad , Neutropenia/complicaciones , Algoritmos , Práctica Clínica Basada en la Evidencia/tendencias , Pautas de la Práctica en Medicina/tendencias , Candidiasis Invasiva/microbiologíaRESUMEN
Complicated intra-abdominal infection requires surgical treatment and broad-spectrum empiric antibiotic treatment used early. The rapid spread of multidrug-resistant bacteria has become a serious threat, especially in critical care units. The excessive use of carbapenems has led to carbapenemase-producing Enterobacteriaceae, leaving tigecycline and colistin as therapeutical options. The new antimicrobials, ceftazidime-avibactam and ceftolozane-tazobactam open new horizons in the treatment of multi-drug resistant Enterobacteriaceae. Candida peritonitis causes a high mortality in the critical patient. Diagnosis and early treatment are associated with a better prognosis, the administration of an echinocandin being of choice in these patients (AU)
La infección intraabdominal complicada requiere tratamiento quirúrgico y tratamiento antibiótico empírico de amplio espectro utilizado de forma precoz. La rápida diseminación de las bacterias multirresistentes se ha convertido en una grave amenaza en las unidades de cuidados críticos. La excesiva utilización de carbapenémicos ha condicionado la aparición de enterobacterias productoras de carbapenemasas, dejando como opciones terapéuticas a tigeciclina y colistina. Los nuevos antimicrobianos, ceftazidima-avibactam y ceftolozano-tazobactam, abren nuevos horizontes en el tratamiento de enterobacterias multirresistentes. La peritonitis candidiásica condiciona una elevada mortalidad en el paciente crítico. El diagnóstico y el tratamiento precoz están asociados con un mejor pronóstico, siendo de elección en estos pacientes la administración de una equinocandina (AU)
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Humanos , Peritonitis/diagnóstico , Peritonitis/tratamiento farmacológico , Microbiota , Antiinfecciosos/uso terapéutico , Infección Hospitalaria/complicaciones , Infección Hospitalaria/tratamiento farmacológico , Resistencia a Múltiples Medicamentos , Colistina/uso terapéutico , Enterobacteriaceae , Candida albicans , Candida albicans/aislamiento & purificación , Diagnóstico PrecozRESUMEN
Introduction: In 2011, a hospital-wide outbreak of OXA-48 producing Klebsiella pneumoniae occurred in our hospital, an epidemiological setting of high ESBL-producing K. pneumoniae rates. This study identifies risk factors for colonization with carbapenemase-producing enterobacteria (CPE) at Surgical Intensive Care Unit (SICU) admission. Methods: A 2-year retrospective study was performed in all patients admitted to the SICU that following routine had a rectal swab collected upon admission. Results: Of 254 patients admitted, 41 (16.1%) harbored CPE (five showing two carbapenemase-producing isolates). Most frequent carbapenemase-producing isolates and carbapenemases were K. pneumoniae (39/46, 84.8%) and OXA-48 (31/46; 76.1%), respectively. Carriers significantly had higher rates of chronic renal disease, previous digestive/biliary endoscopy, hospitalization, ICU/SICU admission, intraabdominal surgery, and antibiotic intake, as well as higher median values of clinical scores (SOFA, SAPS II and APACHE II). In the multivariate analysis (R2 = 0.309, p < 0.001), CPE carriage was associated with prior administration of 3rd-4th generation cephalosporins (OR = 27.96, 95%CI = 6.88, 113.58, p < 0.001), β -lactam/ β -lactamase inhibitor (OR = 11.71, 95%CI = 4.51, 30.43, p < 0.001), abdominal surgery (OR = 6.33, 95%CI = 2.12, 18.89, p = 0.001), and prior digestive/biliary endoscopy (OR = 3.88, 95%CI = 1.56, 9.67, p = 0.004). Conclusions: A strong association between production of ESBLs and carriage of CPE (mainly OXA-48 producing K. pneumoniae) was found. According to the model, the co-selection of β-lactamases by previous exposure to broad-spectrum cephalosporins and β-lactam/ β -lactamase inhibitors (with lower relative risk), abdominal surgery and prior digestive/biliary endoscopy were factors associated with CPE carriage (AU)
Introducción: En 2011 se produjo un brote epidémico de Klebsiella pneumoniae productor de OXA-48 en nuestro hospital, un entorno epidemiológico de altas tasas de K. pneumoniae productor de BLEE. Este estudio identifica factores de riesgo de colonización por enterobacterias productoras de carbapenemasas (EPC) en el momento del ingreso en la unidad de cuidados críticos quirúrgicos (UCCQ). Métodos: Se realizó un estudio retrospectivo durante 2 años en todos los pacientes ingresados en la UCCQ a los que, siguiendo la rutina habitual, se les tomaba un hisopo rectal en el momento de ingreso. Resultados: De los 254 pacientes ingresados, 41 (16,1%) portaban EPC (5 con 2 aislados productores de carbapenemasas). Los aislados productores de carbapenemasas y las carbapenemasas más frecuentes fueron K. pneumoniae (39/46, 84,8%) y OXA-48 (31/46; 76,1%), respectivamente. Los portadores presentaban de forma significativa mayor frecuencia de insuficiencia renal crónica, historia previa de endoscopia digestiva/biliar, hospitalización, ingreso previo en UCI/UCCQ, cirugía intraabdominal y exposición a antibióticos, así como valores más altos (mediana) de SOFA, SAPS II y APACHE II. En el análisis multivariado (R2 = 0,309; p < 0,001), el estado de portador de EPC se asoció con la administración previa de cefalosporinas de amplio espectro (OR = 27,96; IC 95%: 6,88-113,58; p < 0,001), β-lactámicos/inhibidores de β -lactamasas (OR = 11,71; IC 95%: 4,51-30,43; p < 0,001), cirugía abdominal (OR = 6,33; IC 95%: 2,12- 18,89; p = 0,001) y endoscopia digestiva/biliar previa (OR = 3,88; IC 95%: 1,56-9,67; p = 0,004). Conclusiones: Se encontró una fuerte asociación entre la producción de BLEE y la portación de EPC (fundamentalmente K. pneumoniae productora de OXA-48). De acuerdo con el modelo, la co-selección de β-lactamasas tras exposición previa a cefalosporinas de amplio espectro y en menor medida a β-lactámicos/inhibidores de β-lactamasas, la cirugía abdominal y la endoscopia digestiva/biliar previa fueron factores asociados a la portación de EPC (AU)
Asunto(s)
Humanos , Infecciones por Klebsiella/epidemiología , Enterobacteriaceae/aislamiento & purificación , Infecciones por Enterobacteriaceae/epidemiología , Klebsiella pneumoniae/aislamiento & purificación , Tamizaje Masivo , Unidades de Cuidados Intensivos/estadística & datos numéricos , Infección Hospitalaria/prevención & control , Monitoreo Epidemiológico/tendencias , Factores de Riesgo , Pruebas Diagnósticas de Rutina , Estudios Retrospectivos , Carbapenémicos/aislamiento & purificaciónRESUMEN
Labor epidural failure is a challenging situation for the obstetric anesthetist, especially when associated to high risk of caesarean delivery, obesity, and difficult airway predictors. Labor epidural failure is still not standardly defined, consequently its incidence is uncertain: improving the knowledge of risk factors related to failure will increase epidural block success rate. Prolonged labors, previous history of epidural failure, and repeated top-ups needed during labor are recognized risk factors for failure. Clinical experience and the use of modern equipment (ultrasound guided blocks), as well as the choice of neuraxial technique (epidural versus combined spinal-epidural) may affect failure rate. Software-controlled infusion pumps seem to increase epidural analgesia success rate. Among non-technical skills, good communication among medical team members and parturient women is another pivotal point to achieve a satisfactory analgesia for labor. Clear algorithms should be promoted where epidural failure during labor or caesarean delivery may occur.
Asunto(s)
Analgesia Epidural , Analgesia Obstétrica , Algoritmos , Cesárea , Femenino , Humanos , Embarazo , Factores de Riesgo , Insuficiencia del TratamientoRESUMEN
Introduction: Even though foreign body aspiration (FBA) is rare in adult patients, they sometimes require the performance of rigid bronchoscopy for its extraction. Ventilation for this procedure is challenging, especially in patients with pulmonary disease. Clinical, diagnostic evaluation and interventions: We described the case of a 71-year old man who presented with a FBA in the left upper lobe associated with a controlateral pneumothorax. After the placement of a pleural drainage, the foreign body was extracted, using rigid bronchoscopy under general anesthesia and high flow jet ventilation with no further hemodynamic or pulmonary complications, suggesting that this technique is safe in patients with pulmonary leaks. Conclusion: In the case described, rigid bronchoscopy minimized the risk of aspiration of blood and detritus due to continuous flow of gas upward, and avoided the increase of the air leak through the pneumothorax thank to limited airway pressures, making it a clear indication.
Introducción: Aunque la aspiración de cuerpos extraños es rara en adultos, requiere en algunas ocasiones la realización de una broncoscopia rígida para su extracción. El modo ventilatorio para este procedimiento es un reto, especialmente en pacientes con enfermedad pulmonar. Clínica, evaluación diagnóstica e intervenciones: Describimos aquí el caso de un paciente de 71 años con aspiración de un cuerpo extraño enclavado a nivel del lóbulo superior izquierdo asociado a un neumotórax contralateral. Después de insertar un tubo de tórax se extrajo el cuerpo extraño utilizando broncoscopia rígida bajo anestesia general y ventilación jet de alto flujo sin complicaciones hemodinámicas o pulmonares adicionales, sugiriendo que esta técnica es segura en pacientes con fugas pulmonares. Conclusiones: En el presente caso clínico, la broncoscopia rígida minimizó el riesgo de aspiración de sangre y detritus gracias a la inyección de un flujo continuo de gas ascendente, y evitó así el incremento de la fuga a través del neumotórax por las presiones limitadas en la vía aérea, constituyendo una indicación clara de esta técnica.